FY2006 1st Amendment 12/21/2005DANNY L. KOLHA GE
CLERK OF THE CIRCUIT COURT
DATE: January 31, 2006
TO: Salvatore Zappulla, Director
Office of Management & Budget
ATTN.• Dave Owens
Grants Manager
FROM. Pamela G. Han ck
Deputy Clerk
At the December 21, 2005, Board of County Commissioner's meeting the Board granted
approval and authorized execution of the following.
Agreement between Monroe County and the Monroe County Sheriffs Office, using funds
provided under the Edward Byrne State and Local Law Enforcement Formula Grant, for the
purchase of one Livescan fingerprint unit.
Amendment to Agreement between Monroe County and Guidance Clinic of the Middle
Keys by substituting the Baker Act and Marchman Act contract document dated October 1, 2005
as Attachment D in place of the contract document dated September 15, 2005.
Enclosed is a duplicate original of each of the above -mentioned for your handling. Should
you have any questions please do not hesitate to contact this office.
cc: County Attorney
Finance
File ,/
AMENDMENT TO AGREEMENT
This Amendment to Agreement is made and entered into this 21st day of December, 2005,
between the BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA, hereinafter
referred to as "COUNTY," and The Guidance Clinic of the Middle Keys, Inc., hereinafter referred to as
"PROVIDER. "
WHEREAS, the COUNTY and the PROVIDER entered into an agreement on October 19, 2005,
regarding the provision of mental health services, including sub-contracted Baker Act and Marchman
Act transportation services, for citizens of Monroe County; and
WHEREAS, PROVIDER has negotiated a new sub-contract for Baker Act and Marchman Act
transportation services, and,
WHEREAS, the COUNTY desires to amend said agreement to include the new Baker Act and
Marchman Act transportation sub-contract; NOW, THEREFORE,
1. The contract is amended by substituting the Baker Act and Marchman Act contract document
dated October 1, 2005 as Attachment D in place of the contract document dated September
15, 2005.
2. All other provisions of the contract dated October 19, 2005, not inconsistent herewith, remain
in full force and effect.
IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed as of
the day'and year first written above.
(SEAL)
ATTEST: DANNYL. KOLHAGE,CLERK
BG:~J
~ ~ cpe~ty Clerk
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BOARD OF COUNTY. OMMISSIONERS
OF MONROE COU FLORIDA
By
Mayor/Chairman
Guidance Clinic of the Middle Keys, Inc.,
(Federal\)' No. ,')CJ -Not f3.LY
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GUIDANCE CLINIC OF THE MIDDLE KEYS, INC.
3000 41 ST STREET, OCEAN
MARATHON, FL 33050
(v) 305/434-9000 / (f) 305/434-9040
October 1, 2005
Evan Guttman
Elanjess LLC
800 Catherine Street
Key West, FL 33040
RE: LETTER OF AGREEMENT
Dear Mr. Guttman:
The Guidance Clinic of the Middle Keys, Inc. (GCMK), hereby enters into an agreement
with Elanjess LLC to provide coordination and transportation services for Baker
Act/Marchman Act (BA/MA) clients throughout Monroe County and to/from Miami-Dade
County as required. The effective term of this agreement is October 1, 2005-
September 30,2006.
GCMK will supply Elanjess with two vehicles, one Chevrolet Caprices meeting Elanjess
maintenance specifications; to be stationed in Key West at an Elanjess location and a
Ford Taurus to be stationed in Marathon at GCMK headquarters.
GCMK will pay for the fuel and maintenance of the two vehicles used for BA/MA
transportation. Elanjess will coordinate the maintenance for the Caprice located in Key
West. Invoices for routine maintenance (labor and parts) on the Caprice will be
forwarded to GCMK Transportation Director for payment. Elanjess will not charge an
extra fee for coordinating the maintenance of the vehicle. Elanjess must obtain prior
approval from the GCMK Transportation Director to initiate major vehicle repairs.
GCMK will coordinate the maintenance for the Taurus located in Marathon.
GCMK will maintain insurance on the Caprice and Taurus. Elanjess will be named as
an "additional insured" for these two cars. Elanjess will report and document accidents
involving GCMK vehicles and incidents involving clients to the proper authorities and
immediately thereafter contact GCMK.
All Elanjess drivers operating GCMK vehicles will hold a minimum of a Class D Florida
Driver's License and be approved for GCMK insurance coverage. Upon execution of
this agreement, Elanjess will fax to GCMK Transportation Director a current list of
drivers - including a copy of the driver's license and social security number for each
driver - for approval to operate GCMK vehicles. Prior to adding a driver, Elanjess will
fax to GCMK Transportation Director or designee a copy of the driver's license and
1
Partially funded by the Florida Department of Children & Families, District 11
~LC'HILDREN
~ &. FAMILIES
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social security number of the person. GCMK will initiate procedures to add the driver to
GCMK vehicle insurance. Elanjess cannot use the driver until it has received written
notification that the driver has been added to the GCMK insurance coverage.
Additionally, Elanjess will fax a copy of picture identification and social security number
for each escort to GCMK Transportation Director or designee. Elanjess cannot use the
escort until it has received written notification that the escort has been approved by
GCMK.
GCMK will supply Elanjess with a cell phone. Elanjess will follow the transportation
protocol and complete the documentation provided as Attachment 1-3 herein.
The following fee structure is established for the period of the agreement:
Maximum
# Roundtri s*
40
Elanjess
Pa ment
$115
$115
$145
$145
$145
$385
$385
$385
Client Picku Point Client Dro -off Point
Key West Key West
Marathon Marathon
Key West Marathon
Marathon Key West
Marathon Ke Lar 0
Marathon Miami-Dade County
Ke Lar 0 Miami-Dade Count
Ke West Miami-Dade Coun
GCMK Preauthorization Required for All Trips Below
Approval for below fees will be granted only when the Marathon BNMA vehicle is engaged with
another BNMA tri that would reclude another icku within a reasonable eriod of time.
Maximum Car Client Pickup Elanjess
# Roundtri s Location Point Client Dro -off Point Pa ment
3 Key West Marathon & Norlh Key Largo $225
5 Key West Marathon & Norlh Miami-Dade Count $385
300
25
Timely payment for services rendered is ensured by adherence to the following
invoicing procedures:
· Elanjess will submit two statements/invoices per month; one covering the trips
made from the first through the fifteenth and one covering trips made from the
sixteenth through the end of the month. Elanjess will send statements/invoices
to GCMK within 5 business days after the end of the billing period.
· Elanjess will include required documentation with each statement/invoice.
· Elanjess statements/invoices for BA/MA trips will be submitted to the attention of
GCMK Stabilization Unit Director.
· GCMK Stabilization Director will review statement/invoice, mediate any
discrepancies with Elanjess, and forward approved invoice to GCMK Finance
Department.
· GCMK will mail payment to Elanjess within 7 working days (Finance Department)
upon receipt of statement/invoice by the Stabilization Unit Director.
2
Partially funded by the Florida Department of Children & Families, District 11
~'('HiLDREN
~ "FAMILIES
This agreement will begin on October 1 , 2005 and will terminate on
September 30, 2006. The agreement can be cancelled by either party with 60 days
written notice.
GCMK and Elanjess enter into this agreement including Attachments 1-3 by affixing
signatures below:
cto
~.
mie Pipher, MS
ice President of Operations, GCMK
an Guttman
Elanjess LLC
Attachments:
1. GCMK Transportation Protocol
2. GCMK Transportation Record and Payment Authorization Sheet
3. Statement
3
Partially funded by the Florida Department of Children & Families, District 11
~ICHILDREN
121 "FAMILIES
ATTACHMENT 1
GUIDANCE CLINIC OF THE MIDDLE KEYS TRANSPORTATION PROTOCOL:
THE TRANSPORTATION OF BAKER ACT AND MARCHMAN ACT CLIENTS
A. Client Related Rules:
1. Confidentially of a client and client related information shall be maintained at
all times.
2. Each client shall be treated with respect and dignity at all times.
3. No information with client information shall be leave the clinic unless part of a
client transfer packet to a designated facility. (No driver/escort shall maintain
a personal copy of the Transportation Record and Payment Authorization
Sheet. )
4. Client transportation within Monroe County may be conducted with a driver
and an escort.
5. Client transportation outside of Monroe County must be made with one driver
and one escort.
6. A client must be observed for any unusual behaviors including hurting
self/others or sudden medical conditions. Report/respond to conditions
immediately to the Nurse on Duty.
7. At the time of pick up for a Baker Act or Marchman Act client, a driver must
obtain the original Baker Act or Marchman Act paper work from the Pick Up
facility. If the original paper work is not available the driver must immediately
report this information to the GCMK Nurse on Duty for further instructions.
8. A female client requires a female escort or a female driver.
9. A parent is not allowed to travel in the Baker Act vehicle with a Baker Act or
Marchman Act minor. Parents may follow in another car.
10. Only one client may be transported at a time in the Baker Act vehicle.
11. Clients are not to smoke in the car.
12. Clients are not to be placed in handcuffs or any type of restraints for any
reason by a driver or escort - or to be placed in the vehicle by others (Le. Law
Enforcement) in handcuffs or any type of restraints
13. A client's movement is not to be impeded with any physical restraint unless
directed by a nurse/MD/law enforcement officer.
14. If a client is violent during transport and poses a treat to safety, stop the
vehicle and call 911, than notify the Nurse on Duty of the situation.
15. A client shall not be left alone in the vehicle during the trip for any reason.
16. A client shall be under the observation of the driver or escort at all times
during the transport.
17. Client is encouraged to use restroom facilities prior to departure. If the trip is
generated from Key West and a stop is required, the GCMK may be used for
that purpose.
18. A client may not use aluminum/metal cans. Items for drinking shall be
provided only in a plastic container.
19. Clients may not have any metal utensils, glass or other hard products such as
\\Stash\srmgmt\Baker Act\05-06\05-06 BA MA rules I .doc
rvsd: 07/21/05
- 1 -
pencils or pens.
20. A client may not shop during a stop. All efforts should be made to avoid stops.
If a stop is required, it should be short and without delay.
21. If a client must use a public facility, the client must be escorted to the
restroom and the driver must remain outside the restroom door until the client
leaves the restroom. The driver will remain in conversation with client while
the client is in the restroom.
B. Coordination of Transportation Rules:
1. Transportation arrangements for Baker Act and Marchman Act clients are
under the direction of the Unit Nurse on Duty/GCMK per contractual
arrangement Elanjess LLC. No other agency is authorized to contact Elanjess
directly for transportation.
2. Final decision for a driver to transport is made by the nurse on duty. The
nurse may request a BAL be conducted or send a drivers/escort home if
he/she has a concern.
3. All trips will be made within the approved fee structure.
4. All trips will be made using the closest vehicle and the shortest distance
unless preauthorization is obtained from the Unit Nurse on Duty at the GCMK.
5. Clients may be picked up at only approved locations. The GCMK Nurse on
Duty will communicate the pick up location. Approved locations will include:
Hospitals, Detention Facility
Mental Health Clinics, Anchor Away
With a GCMK staff member
6. At Depoo: Call security with phone located on the first floor.
7. At GCMK: Use the telephone call box next to the elevator.
8. At GCMK, staff members shall place the client in the vehicle for departure and
will assist the client from the vehicle at time of arrival.
9. The facility responsible for the departing client for a trip longer than 2 hours
shall provide a brown bag snack. All minors shall be supplied with a snack for
any trip over 1 hour.
10. When a driver reports a client is too dangerous to transport, the nurse on duty
shall work with the Sheriff's department to transport the client the client to the
nearest emergency room.
11. If a client absconds at time of or during transport, immediately report the
information to the GCMK Nurse on Duty. Do not go after the client.
12. "Jail Hold" clients from the Monroe County Detention Facility shall be picked
up from the Sallyport area only. To access the Sallyport area, the driver must
drive the car within 1 foot of the Sallyport entrance. If the door does not open,
the escort must use the speaker mounted on the wall next to the Sallyport
entrance to request entrance. Once inside, Detention Facility staff will bring
the client to the car. When the client is inside the car and the doors are
locked, the Sallyport area exit doors will open.
13. The driver/escort must determine from the Pick Up facility if the client has
been searched and encourage staff to conduct a search prior to transport. If
\\Stash\snngmt\Baker Act\05-06\05-06 BA MA rulesl.doc
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- 2 -
the client is not searched prior to transport, the driver must communicate this
information to the Duty Staff Member prior to opening the client door at the
Designation point.
14. Driver/escort must respond to the pick up point within 1 hour and 15 minutes.
C. Reimbursement related rules
1. All cancelled and otherwise diverted trips will be reported on the
Transportation Record and Payment Authorization Sheet.
2. Transportation Record and Payment Authorization Sheets and a Statement of
services rendered will be faxed to the Stabilization Unit Director on the first
and sixteenth of each month.
3. If the driver arrives without the original Baker or Marchman Act paperwork,
Elanjess will obtain the paper work without charge to the GCMK.
\\Stash\srmgmt\Baker Act\05-06\05-06 BA MA rulesl.doc
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- 3 -
ATTACHMENT 2
GUIDANCE CLINIC OF THE MIDDLE KEYS
3000 41sT ST. Ocean
Marathon, FL 33050
Voice 305-434-9000 . Fax 305-434-9040
TRANSPORTATION RECORD AND PAYMENT AUTHORIZATION SHEET
Transportation Type: 0 Baker Act
o Marchman Act
Date: Client Name:
DOB:
Time Called:
Time of Pick Up:
Time of Drop Off:
Time van returned to Duty:
Vehicle:
KW vehicle
Mar vehicle
Place of Pick Up:
(Where did you pick up the Client: Facility Name/City)
Authorized Staff Signature at Pick Up Facility:
Time:
Destination:
(Where did you take the Client: Facility Name/City)
Authorized Staff Signature at Designation Facility:
(Staff member accepting client)
Time:
Driver Name:
Escort Name:
Beginning Miles:
Pick Up Miles:
Drop Off Miles:
Ending Miles:
r':ORGCMKUSE-ONly:-------------------------------------------------1
I Amount to be paid: !
I Stabilization Unit Director Signature: I
' ,
' ,
' ,
1---------------------------------------------------------------------------------__________________________________________________________________________________---------------------______________J
. ATTACHMENT 3
Statement
Date:
Elanjess LLC
800 Catherine St.
Key West, Florida 33040
Stabilization Unit Director
Guidance Clinic of the Middle Keys
3000 41st St. Ocean
Marathon, FL 33050
Re: Baker Act and Marchman Act transportation
The following is a break down for trips from
to
Date Name Pick Up Cost Vehicle
Designation 1 2 3
TOTAL
Elanjess LLC Representative Signature
GCMK CFO Signature
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GUIDANCE CLINIC OF THE MIDDLE KEYS, INC.
300041sT STREET, OCEAN
MARATHON, FL 33050
(v) 305/434-9000 / (f) 305/434-9040
September 15, 2005
Darren Guttman
Elanjess LLC a.k.a. Jessrica Corp.
800 Catherine Street
Key West, FL 33040
RE: LETTER OF AGREEMENT
Dear Mr. Guttman:
The Guidance Clinic of the Middle Keys, Inc. (GCMK), hereby enters into an agreement with
Elanjess LLC to provide coordination and transportation services for Baker Act/Marchman Act
(BA/MA) clients throughout Monroe County and to/from Miami-Dade County as required. The
effective term of this agreement is October 1, 2005 -September 30, 2006.
GCMK will transfer ownership of the 1995 Chevrolet Caprice to Elanjess. Elanjess will supply
an additional car with the same safety features. One vehicle will be stationed in Key West at
an Elanjess location and the other will be stationed in Marathon in a designated parking space
at GCMK headquarters.
GCMK will continue to be responsible for the cost of fuel and Elanjess will be responsible for
any and all upkeep and maintenance of the two vehicles used for BA/MA transportation.
Elanjess is also responsible for tolls, cell phone/beeper and vehicle insurance expenses.
Elanjess will not charge an extra fee for coordinating the maintenance of the vehicle.
Elanjess will maintain ownership and insurance on both of the designated vehicles and GCMK
will be named as an "additional insured" for both cars on Elanjess's vehicle policy. All Elanjess
drivers operating designated BA/MA vehicles will meet Florida State license requirements.
Elanjess will ensure the minimum liability insurance requirement of $100,000 per person and
$200,000 per incident. Elanjess will report and document accidents and incidents involving
clients to the proper authorities and immediately thereafter contact GCMK.
Elanjess will supply a designated cell phone for each of the two Baker Act vehicles. Elanjess
drivers will have one of these cell phones available for each BA/MA run. Elanjess will
communicate the cell phone number to GCMK's Charge Nurse that will be used during each
BA/MA run. Elanjess will follow the most current copy of the Transportation Protocol and
complete the documentation provided as Attachment 1-3 herein.
1
~~O'ID'" PI'AI.T,II/\INTOI
CHILDREN
Partially funded by the Florida Department of Children & Families, District 11 <:)" FAMILIES
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The fOllowing fee structure is established for the period of the agreement:
Maximum
# Roundtri s*
Client Picku Point
Elanjess Payment
Per Tri
325
ANY In-Count Tri s
$140
$430
85
Timely payment for services rendered is ensured by adherence to the following invoicing
procedures;
· Elanjess will submit two Statements per month; one covering the trips made from the
first through the fifteenth and one covering trips made from the sixteenth through the
end of the month. Elanjess will send Statements to GCMK within 5 business days after
the end of the bilfing period.
· Elanjess will include the required Transportation Record and Payment Authorization
Sheet for each trip indicated on the Statement.
· Elanjess Statements for BAlMA trips will be submitted to the attention of GCMK
Stabilization Unit Director.
· GCMK's Stabilization Director will review Statement, mediate any discrepancies with
Elanjess, and forward approved invoice to GCMK's Finance Department.
· GCMK (Finance Department) will mail payment to Elanjess within 7 working days upon
receipt of Statement by the Stabilization Unit Director.
This agreement will begin on October 1, 2005, and wilf terminate on
September 30, 2006. The agreement can be cancelled by either party with 60 days written
notice.
GCMK and Elanjess enter into this agreement including Attachments 1-3 by affixing signatures
below:
~~
Darren Guttman
ElanJess Ltc
Attachments:
1. GCMK Transportation Protocol
2. GCMK Transportation Record and Payment Authorization Sheet
3. Statement
2
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14I004
A IT ACHMENT 1
GUIDANCE CLINIC OF THE MIDDLE KEYS TRANSPORTATION PROTOCOL:
THE TRANSPORTATION OF BAKER ACT AND MARCHMAN ACT CLIENTS
A. Client Related Rules:
1. Confidentiality of a client and client related information shall be maintained at all
times.
2. Each client shall be treated with respect and dignity at all times.
3. No information with client information shall leave the clinic unless part of a client
transfer packet to a designated facility. (No driver/escort shall maintain a
personal copy of the Transportation Record and Payment Authorization Sheet.)
4. All drivers and escorts must be approved by the Transportation Department of
the GCMK prior to accepting a driving assignment.
5. Client transportation within Monroe County may be conducted with a driver and
an escort.
6. Client transportation outside at Monroe County must be made with one driver
and one escort.
7. A client must be observed for any unusual behaviors including hurting self/others
or sudden medical conditions. Report/respond to conditions immediately to the
Nurse on Duty.
8. At the time of pick up for a Baker Act or Marchman Act client, a driver must
obtain the original Baker Act or Marchman Act paper work from the Pick Up
facility. If the original paper work is not available the driver must immediately
report this information to the GCMK Nurse on Duty for further instructions.
9. A female client requires a female escort or a female driver.
10. A parent is not allowed to travel in the Baker Act vehicle with a Baker Act or
Marchman Act minor. Parents may follow in another car.
11. Only one client may be transported at a time in the Baker Act vehicle.
12. Clients are not to smoke in the car.
13. Clients are not to be placed in handcuffs or any type of restraints for any reason
by a driver or escort.
14.A client's movement is not to be impeded with any physical restraint unless
directed by a nurse/MDllaw enforcement officer.
15.lt a client is violent during transport and poses a treat to safety, stop the vehicle
and call 911, then notify the Nurse on Duty of the situation.
16. A client shall not be left alone in the vehicle during the trip for any reason.
17.A client shall be under the observation of the driver or escort at all times during
the transport.
18. Client is encouraged 10 use restroom facilities prior to departure. If the trip is
generated from Key West and a stop is required, the GCMK may be used for that
purpose.
19. A client may not use aluminUm/metal cans. Items for drinking shall be provided
only in a plastic container.
20. Clients may not have any metal utensils, glass or other hard products such as
Sr mgntJ/04/05 BA MA Rules.doc
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pencils or pens.
21.A client may not shop during a stop. All efforts should be made to avoid stops. If
a stop is required, it should be short and without delay.
22. If a client must use a public facility, the client must be escorted to the restroom
and the driver must remain outside the restroom door until the client leaves the
restroom. The driver will remain in conversation with client while the client is in
the restroom.
B. Coordination of Transportation Rules:
1. Transportation arrangements for Baker Act and Marchman Act clients are under
the direction of the Unit Nurse on Duty/GCMK per contractual arrangement
Elanjess LLC . No other agency is authorized to contact Elanjess directly for
transportation.
2. Final decision for a driver to transport is made by the nurse on duty. The nurse
may request a BAL be conducted or send a drivers/escort home If he/she has a
concern.
3. All trips will be made within the approved fee structure.
4. All trips will be made using the closest vehicle and the shortest distance unless
preauthorization is obtained from the Unit Nurse on Duty at the GCMK.
5. Clients may be picked up at only approved locations. The GCMK Nurse on Duty
will communicate the pick up location. Approved locations will include:
Hospitals Detention Facility
Mental Health Clinics Anchor Away
With a GCMK staff member
6. At OePoo: Call security with phone located on the first floor.
7. At GCMK: Use the telephone call box next to the elevator.
8. At GCMK, staff members shall place the client in the vehicle for departure and will
assist the client from the vehicle at time of arrival.
9. The facility responsible for the departing client for a trip longer than 2 hours shall
provide a brown bag snack. All minors shall be supplied with a snack for any trip
over 1 hour.
10. When a driver reports a client is too dangerous to transport, the nurse on duty
shall work with the Sherifrs department to transport the client the client to the
nearest emergency room.
11. If a client absconds at time of or during transport, immediately report the
information to the GCMK Nurse on Duty. Do not go after the client.
12. "Jail Hold" clients from the Monroe County Detention Facility shall be picked up
from the Sallyport area only. To access the Sallyport area, the driver must drive
the car within 1 foot of the Sallyport entrance. If the door does not open, the
escort must use the speaker mounted on the wall next to the Saflyport entrance
to request entrance. Once inside, Detention Facility staff will bring the client to
the car. When the client is inside the car and the doors are locked, the Sallyport
area exit doors will open.
13. The driver/escort must determine from the Pick Up facility if the client has been
searched and encourage staff to conduct a search prior to transport. If the client
Sr mgnt//04/05 BA MA Rules.doc
2
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is not searched prior to transport, the driver must communicate this information to
the Duty Staff Member prior to opening the client door at the Designation point.
14. Driver/escort must respond to the pick up point within 1 hour and 15 minutes.
C. Reimbursement related rules
1. All cancelled and otherwise diverted trips will be reported on the Transportation
Record and Payment Authorization Sheet.
2. Daily inspection checklist will be maintained for all Baker Act vehicles and sent
monthly to the GCMK Transportation Coordinator.
3. Transportation Record and Payment Authorization Sheets and a Statement of
services rendered will be faxed to the Stabilization Unit Director on the first and
sixteenth of each month.
4. If the driver arrives without the original Baker or Marchman Act paperwork,
Elanjess will obtain the paper work without charge to the GCMK.
Sr mgntl/04/05 BA MA Rules.doc
3
LV/V~/~VVv 10:U, ~AA 3Ub434~U4U
GCMK
14I 007
ATTACHMENT 2
GUIDANCE CLINIC OF THE MIDDLE KEYS
3000 41sT ST. Ocean
Marathon, FL 33050
Voice 305-434-9000 . Fax 305-434-9040
TRANSPORTATION RECORD AND PAYMENT AUTHORIZATION SHEET
Transportation Type: 0 Baker Act
o Marchman Act
Date: Client Name:
OOB:
Time Called:
Time of Pick Up:
Time of Drop Off:
Time van returned to Duty:
Vehicle: 0 KW Caprice
o Mar Caprice
o Crown Victoria
,----------------------------------------------------------------------------------------------1
I Place of Pick Up: i
! (Where did you pick up the Client: Facility Name/City)
I
I Authorized Staff Signature at Pick Up Facility:
I
I
I
,
I
!
--.--~--------~-------------------~.___......__...i
Time:
r-...--------.---.--..----
..---------.-----------.-----------..---1
Destination:
(Where did you take the Client: Facility Name/City)
Authorized Staff Signature at Designation Facility:
Time:
(Staff member accepting client)
---------------------------------______1
Driver Name:
Escort Name:
Beginning Miles:
Pick Up Miles:
Drop Off Miles:
Ending Miles:
'FOR GCMK USE ONLV:------ -------------------------------1
In i
I Amount to be paid: j
t Stabilization Unit Director Signature: J'
._------------~--_._-----~-------------_.._._----------------------------------------------
~U/Uv/~UUU ~o;u, ~^A JU~4~4~U4U
GCMK
~008
ATTACHMENT 3
Statement
Date:
Elanjess LLC
800 Catherine St.
Key West, Florida 33040
Stabilization Unit Director
Guidance Clinic of the Middle Keys
3000 41st St. Ocean
Marathon. FL 33050
Re: Baker Act and Marchman Act transportation
The following is a break down for trips from
to
Date Name Pick Up Cost Vehicle
Designation 1 2 3
TOTAL
Elanjess LLC Representative Signature
GCMK CFO Signature